Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clark County Rehabilitation & Living Center during CMS and state inspections, most recent first.
Multiple cognitively impaired residents with known behavioral or wandering histories physically assaulted other residents in separate incidents. In one case, a resident with an impulse disorder struck another resident who verbally intervened when staff attempted to redirect him from taking a meal tray. In another, a resident with a conduct disorder punched a wandering resident who entered his room and could not be redirected. A third incident occurred when a resident with severe dementia and wandering behaviors entered another resident’s room, took his blanket, and hit him when he tried to retrieve it. In the fourth incident, a severely cognitively impaired, wandering resident grabbed and yelled at another resident over a TV remote. These events occurred despite documented cognitive and behavioral issues and an abuse policy stating residents will be free from abuse and protected from harm.
The facility failed to follow its abuse policy by not removing staff implicated in abuse or misconduct allegations from resident care and by not conducting thorough investigations. In one case, a resident with a serious mental health condition alleged abuse by a CNA, yet the CNA continued to work multiple shifts during the investigation. In another case, a resident with paraplegia and anxiety alleged that a floating CNA stole his clothing; the CNA continued working and no residents were interviewed as part of the investigation. In a third incident, a resident with dementia who wandered into another resident’s room was punched multiple times by that resident, who had a history of behavioral issues, and the subsequent investigation relied on only one staff interview.
Food service staff did not follow required food safety practices during meal preparation and distribution. Surveyors observed uncovered and undated pitchers and other food items in refrigerators, freezers without thermometers, a portable steam table moved between units with food exposed in the hallway, and a towel resting inside a pan of food. A dietary aide also failed to perform hand hygiene while serving meals, and meal temperatures were not maintained, with cold drinks left on carts and hot foods measured below expected serving temperatures.
The facility failed to maintain infection control practices for multiple residents and staff. Staff returned to work after GI symptoms sooner than the facility policy required, a Hoyer lift was moved between residents without being sanitized, one resident with a Foley catheter was not placed on EBP despite the care plan, and another resident’s catheter bag was observed hanging from a garbage can.
Failure to accommodate a resident’s toileting needs and preferences. A cognitively intact resident with autism, schizotypal disorder, and moderate ID had the bathroom attached to his room locked after prior incidents of washing up in the toilet. Staff said he had to go down the hall to a bathing room to toilet and find someone to unlock the door, including at night. Surveyors observed the locked bathroom, the resident using a urinal in his room, and the resident stating he had to ask staff to unlock the toilet room and, "What choice do I have." The record showed a shared shower room waiver, but no consent authorizing the bathroom to remain locked, and staff were unsure when the resident was last reassessed for the behavior.
A resident with intact cognition and a restorative ambulation program was not consistently assisted to the therapy room as requested and care planned. Staff on the unit were unsure about the program, did not reliably ambulate him or take him to therapy at shift change, and the resident was left waiting in his room or recliner before eventually walking on his own with his walker.
A resident with schizophrenia, altered mental status, weakness, repeated falls, and total mobility dependence did not have a bed alarm in place as identified in the care plan. Surveyors observed CNA staff providing care while the alarm was missing, and staff could not say how long it had been off or who removed it. Records showed several prior falls from or beside the bed, including one where the bed alarm did not sound because it was positioned too low.
A facility failed to provide ongoing pre- and post-dialysis assessment and monitoring for two residents receiving hemodialysis. Both residents had ESRD and complex medical conditions, and their care plans and MD orders required vitals before and after dialysis, along with access-site checks and monitoring for bleeding or infection. Records lacked documented vitals in the MAR/TAR, access-site assessments were not documented, and the DON stated there was no policy and procedure for dialysis assessments.
The facility did not ensure all staff received required training on abuse, neglect, exploitation, and dementia care, as evidenced by missing or incomplete education records for several staff members and confirmation from the DON that some new hires and casual staff had not completed necessary training. This deficiency has the potential to affect all residents.
The facility failed to follow its abuse prevention and reporting policies after two residents were subjected to inappropriate physical restraint and medication administration, and allegations of abuse were not reported to the state agency or law enforcement. Staff involved continued to work after the incidents, required notifications and investigations were not completed, and staff training on abuse prevention was inconsistent and inadequately documented.
A resident with severe cognitive impairment and a court-appointed guardian was involved in a substantiated abuse incident. Despite facility policy and the resident's care plan requiring notification, the guardian was not informed of the incident or the investigation findings. The DON could not provide documentation of any such notification, and the guardian confirmed she was unaware of the event.
Staff used physical force to administer court-ordered psychotropic medications to a resident with severe cognitive impairment, holding the resident's arms and face despite the absence of aggression. The care plan directed disguising medications in food or drink and did not authorize physical restraints, nor was there a physician order for such use. Documentation failed to reflect alternative interventions or reasons for refusals, and the incident was later substantiated through staff interviews and facility investigation.
The facility did not follow required procedures for reporting and investigating allegations of abuse involving two residents with cognitive and psychiatric conditions. In both cases, allegations were not reported to the State Agency or law enforcement as required, and staff decisions were influenced by prior unfounded reports and concerns about late reporting.
A resident with cognitive and psychiatric diagnoses was the subject of an abuse allegation reported by a family member to law enforcement. Although police visited the facility and staff notified supervisory and protective parties, no investigation into the abuse allegation was conducted, contrary to facility policy. The DON stated that prior similar allegations were unfounded and did not believe this report required investigation.
A resident with multiple psychiatric diagnoses received prescription medications administered by a CNA, who had not completed medication administration training, using physical assistance and under direct RN supervision. This practice was contrary to facility policy, which restricts medication administration to licensed staff, and resulted in a deficiency.
Three cognitively intact residents with significant medical conditions repeatedly voiced concerns about staff shortages, long call light response times, and overheard staff conversations in resident council meetings, but did not receive timely updates or follow-up from administration or staff, contrary to facility policy. Interviews confirmed a lack of formal process for addressing and communicating actions taken on these concerns.
Two residents with cognitive impairment were involved in separate incidents of verbal and physical abuse, including one resident being threatened and another being struck in the face by a peer. Both incidents resulted in injury and were confirmed by the DON as abuse.
Two residents, both cognitively intact, were involved in a physical altercation after a verbal dispute. Although the facility's policy required a thorough investigation including resident statements, staff did not interview other residents or take further investigative steps, and the DON considered the event isolated, resulting in an incomplete investigation.
A resident with a history of chronic suicidal ideation expressed a desire to kill herself, but CNAs failed to follow the care plan by not notifying nursing staff or providing required supervision. Instead, the resident was left alone in her room, and the incident was not documented in the progress notes or communicated to the nurse or Nurse Care Coordinator. The care plan's interventions, including immediate assessment and one-to-one supervision, were not implemented.
Two residents at risk for falls were subjected to the use of multiple alarms without consistent implementation of non-alarm interventions or a documented plan to reduce alarm use. Despite facility policy requiring short-term alarm use and regular review, both residents had several alarms in place simultaneously, with incomplete assessments and missing documentation of alternative strategies. Alarms failed to prevent falls, and care plan interventions such as gait belt use were not consistently followed.
A resident's right to privacy was violated when facility staff opened their mail without permission. The resident, who is cognitively intact and a registered sex offender, had previously signed a waiver during probation allowing mail to be opened, but this probation ended years ago. Despite this, the facility continued the practice without a current waiver, contrary to their policy on mail privacy.
The facility did not conduct annual performance reviews for CNAs, affecting three CNAs and potentially impacting all 147 residents. The HR Manager confirmed the absence of a system for conducting these reviews.
A facility failed to report a resident-to-resident altercation and submit the required investigation within the stipulated timeframe. A resident with dementia and behavioral issues attempted to take candy from another resident, resulting in a willful slap. Despite the care plan's interventions, the incident occurred, and the DON acknowledged it should have been reported as willful misconduct.
The facility failed to provide written transfer notices to two residents who were hospitalized. One resident, who was cognitively intact, requested a hospital transfer due to a fever but did not receive a written notice. Another resident with multiple diagnoses was also transferred without a written notice. The DON confirmed that the facility does not issue such notifications.
A resident with Huntington's disease and pneumonitis required the head of the bed to be elevated during and after tube feeding, as per their care plan. However, a surveyor observed that the resident was positioned flat during feeding, contrary to the care plan. RN C acknowledged the oversight and adjusted the bed after being prompted. Discussions with RN D and the DON confirmed the expectation to follow the care plan, highlighting a deficiency in care implementation.
A facility failed to provide adequate supervision and safety measures for two residents. One resident, with dementia and seizure disorder, experienced falls due to improperly placed chair alarms. Another resident, with behavioral issues, was involved in an altercation due to insufficient 1:1 supervision by a new CNA. The incidents highlight lapses in following care plans and staff training.
The facility did not follow professional standards for food service safety by transporting uncovered food items to residents' rooms. CNAs were observed carrying trays with uncovered cake and drinks to three residents, contrary to the facility's policy requiring all food to be covered during transport. The Director of Hospitality acknowledged that food and drinks should be covered when leaving the dining area.
A facility failed to ensure a resident received a pneumococcal vaccine. The resident, with severe cognitive impairment and chronic conditions, was admitted without proper immunization review. The Infection Preventionist and RN could not provide proof of vaccination or a clear process for residents transferring between units, leading to the oversight.
A resident developed a stage 2 pressure injury on the coccyx, which healed over a month later. The facility failed to update the resident's care plan or repositioning schedule to prevent further pressure injuries, despite the resident's immobility and incontinence. Observations showed the resident was seated in a wheelchair for extended periods without repositioning, and staff were unaware of necessary changes to the care plan.
The facility failed to timely report an allegation of sexual abuse involving a resident with multiple diagnoses. A family member reported the allegation to a nurse, but it was not reported to the State Agency or police until several days later, violating the requirement to report within 2 hours.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents. One incident involved a resident with moderately impaired cognition and an impulse disorder who attempted to take another resident’s meal tray. When a CNA tried to redirect him, he became agitated. Another resident, who was helping place trays on tables, verbally confronted him about his behavior toward the CNA. In response, the impulsive resident struck the intervening resident on one arm, and when the resident laughed, he struck the other arm before the CNA could intervene. The resident who struck the other had a care plan noting impaired cognition, an impulse disorder, and a history of impulsive behaviors. A second incident involved a cognitively impaired resident with a history of wandering who entered another resident’s room and could not be redirected by the CNA. The room’s occupant, a resident with a conduct disorder and a history of behavior toward others, yelled at the wandering resident and then got out of bed and punched him three times in the left upper arm with a closed fist. The wandering resident then left the room and sat in a chair in the hallway. Both residents had documented cognitive impairment, and the aggressor had a known behavioral history, yet the altercation still occurred when the wandering resident entered his room and staff were unable to redirect him. A third incident involved a resident with severe cognitive impairment, Alzheimer’s disease, dementia with agitation, and documented physical, verbal, and wandering behaviors who entered another severely cognitively impaired resident’s room, mistakenly believing it was his own, and took the other resident’s blanket. The room’s occupant became upset and tried to remove the intruding resident and retrieve his blanket, leading the intruder to hit him in the chest and shoulder. The CNA heard yelling, found both residents in the room, and observed them hitting each other before separating them. Both residents had severe cognitive impairment, and one had known wandering and behavioral issues. A fourth incident involved a resident with moderate cognitive impairment and no documented behavioral symptoms during assessment who was watching television when another resident with severe cognitive impairment and wandering behaviors came out, picked up the remote, changed the channel, and set the remote down. When the first resident picked up the remote to change the channel back, the cognitively impaired, wandering resident grabbed his wrist and yelled and swore at him, telling him to leave it alone. The two residents then yelled at each other until staff separated them. The facility’s abuse policy states that each resident will be free from abuse, including physical abuse, and that residents will be protected from abuse, neglect, and harm while residing at the facility, but these resident-to-resident physical altercations occurred despite known cognitive and behavioral issues in the aggressor residents.
Failure to Remove Alleged Abusers and Conduct Thorough Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to remove staff members implicated in abuse allegations from resident care and to conduct complete investigations into those allegations. For one resident with schizoaffective disorder–bipolar type, an abuse allegation was documented on a misconduct incident report dated 02/20/26 involving a CNA and another resident. The DON confirmed that the CNA remained on the work schedule throughout the investigation, despite the facility’s abuse policy requiring immediate removal of alleged perpetrators from the facility pending investigation. Timecard records show that this CNA continued to work multiple shifts on and after the date of the allegation. In a separate incident, a resident with paraplegia due to thoracic spinal cord injury and an anxiety disorder alleged that a floating CNA had stolen his red long-sleeved shirt. The misconduct incident report documented that the resident was upset and expressed harm toward the CNA, and the DON stated that the CNA was reassigned to another unit during the investigation. However, the resident reported that the CNA was told only to stay away from him and that the CNA was not removed from resident care. Timecard records confirm that the CNA continued to work multiple shifts during the investigation period. The DON also confirmed that no residents were interviewed as part of this investigation, and the facility had no evidence of any resident interviews. Another deficiency occurred in the investigation of an incident in which a resident with dementia and a history of wandering entered the room of a resident with conduct disorder and a history of behavior toward others. According to the misconduct incident report dated 2/16/26, the wandering resident repeatedly entered the other resident’s room despite redirection attempts by a CNA, leading the resident in the room to get out of bed and punch the wandering resident three times on the left upper arm before the wandering resident left and sat in a hallway chair. The DON later confirmed that only one staff member, the CNA involved, was interviewed during the investigation and acknowledged that all staff should have been interviewed, indicating that the investigation was not complete or thorough. The facility’s abuse policy states that residents will be protected from alleged offenders and that alleged perpetrators will be immediately removed from the facility pending a thorough investigation, which was not followed in these cases.
Food Storage, Handling, and Temperature Control Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. Surveyors observed multiple instances of food and beverages left uncovered, unlabeled, or undated, including pitchers of unknown liquid in refrigerators on several units, a glass bottle of unknown liquid without labeling, and carafes of juice and a baggie of macaroni and cheese stored on the coffee bar refrigerator without being covered or dated. Surveyors also observed freezers on units without thermometers present, and staff interviewed were unaware of who monitored refrigerator and freezer temperatures on the units. During meal service, surveyors observed dietary staff not performing hand hygiene while serving food. One dietary aide adjusted eyeglasses and clothing, used a walkie talkie, and removed a glove during meal service without washing hands. Surveyors also observed a portable steam table being moved between units with food uncovered in the hallway after the foil covering had been torn open. On another occasion, the steam table was covered with a towel, but part of the towel was resting inside a pan of mashed potatoes. A plastic pitcher was also observed sitting in a bowl of elbow macaroni being used as a scoop, and the macaroni was not covered. Meal temperatures were also not maintained as expected. Surveyors observed breakfast food delivered later than the scheduled time, with pancakes appearing dry and butter not melting. On a later meal observation, drinks for residents were sitting on the cart without a way to keep them cold, and a test tray showed chocolate milk at 52 degrees while hot food items ranged from 98 to 128 degrees. Resident council members reported that meals were late at times and the food was cold, and the DON stated food should be dated and covered when stored and served at proper temperatures.
Infection Prevention and Control Failures
Penalty
Summary
The facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for all 144 residents. Facility policy for viral gastroenteritis, including norovirus, stated symptomatic staff were to remain off duty until symptom-free for at least 48 hours, but the infection line list showed two staff members returned to work less than 48 hours after gastrointestinal symptoms were reported. One staff member reported vomiting and diarrhea and returned to work the next day after being off work for several days, and another staff member reported vomiting and returned to work the following day. The Infection Preventionist stated that if the facility was not in outbreak, staff could return to work 24 hours after gastrointestinal symptoms resolved, and the Dietary Manager stated ill dietary staff were reported to the Infection Preventionist, who informed staff when they could return to work. The facility also failed to sanitize shared equipment between residents when a Hoyer lift was removed from one resident room and taken to another without being sanitized. In addition, a resident with diagnoses including BPH and urinary retention had a Foley catheter and was care planned for EBP due to the urinary catheter, but the resident did not have EBP signs on the door or PPE on the back of the door after transfer to a different floor. Staff stated the resident should have been on EBP and that licensed nursing staff or the NCC were responsible for ensuring it was in place. Another resident with dementia and an indwelling catheter was observed with the catheter bag hanging from the garbage can next to the recliner, and the NCC acknowledged this was not facility practice.
Failure to Accommodate Resident Toileting Needs
Penalty
Summary
The facility did not ensure accommodation of a resident’s toileting needs and preferences. The resident had diagnoses including autistic disorder, schizotypal disorder, and moderate intellectual disabilities, and had a BIMS score of 15/15. Although the resident was documented as continent of bladder and bowel on the MDS, the care plan noted that the resident’s bathroom attached to the bedroom was locked after the resident was found washing up in the toilet on multiple occasions. The care plan also included supervision in the big bathroom and stated the attached bathroom was locked for infection control purposes, but no interventions were documented for meeting toileting needs under behavioral or psychosocial needs. Surveyors observed that the bathroom attached to the resident’s room had no doorknob and was locked. Staff stated the resident went down the hall to a bathing room to use the toilet, and that the resident had to find a staff member to unlock the bathing room door when needing to toilet. The bathing room contained a toilet, sink, call light, and stored transfer equipment, and was also being used as a storage space. The resident was observed in bed with a urinal on the floor and stated he used the bathroom down the hall for bowel movements and at night, and that he had to find staff to unlock the door. The resident stated, "What choice do I have." The resident’s record contained a universal bathroom/shower room waiver signed by the legal representative allowing use of a shared shower room, but there was no consent in the medical record authorizing the resident’s bathroom door to be locked and preventing use of the toilet. The legal representative confirmed awareness that the bathroom door was locked and that the resident used the bathing room toilet at times. Facility staff stated the resident had a long-standing history of psychotic behaviors, including hoarding and aggressiveness, and that the bathroom was locked because the resident had previously washed up in the toilet. Staff were not aware of when the resident was last reevaluated for this behavior, and no documentation was found showing continued behavior monitoring or a trial of personal bathroom use since the 2022 incidents.
Failure to Support Resident Choice for Restorative Therapy Access
Penalty
Summary
The facility did not ensure that a resident with intact cognition and self-determination rights was supported in a choice that was significant to him: going to the therapy room to complete independent exercises and ambulation daily. The resident was admitted with diagnoses including heart failure, COPD, atrial fibrillation, anxiety, history of falling, and chronic pain, and his care plan included taking him to the therapy room at shift report Monday through Friday, along with a restorative walking program. He was his own decision maker, and his care plan also reflected his request to continue exercising independently even after therapy ended. After the resident moved to a different unit, he reported that staff did not take him to the therapy room and told him there was not enough staff or that therapy staff would take him. Surveyor observation and interviews showed that on multiple occasions staff did not ambulate him or assist him to therapy as planned. The resident remained in his room or recliner waiting for the planned assistance, and when he asked about it, staff on the unit were unsure whether he had a restorative program or whether they were responsible for taking him. On one observed shift change, the resident told oncoming CNAs he was supposed to walk to the nurse's station and then go to therapy, but staff were uncertain and did not immediately assist him. The resident eventually began ambulating on his own with his walker after waiting, and he became upset while telling staff he had been waiting for help. Interviews with nursing and restorative staff confirmed the resident had a restorative ambulation program and that staff should have been walking him, but the plan was not consistently carried out as written.
Missing Bed Alarm for Resident With Repeated Falls
Penalty
Summary
The facility did not ensure the resident environment remained free from accidental hazards with adequate supervision and assistance devices for a resident with schizophrenia, altered mental status, weakness, repeated falls, and a BIMS score of 99 indicating the resident was unable to complete the interview. The resident’s MDS stated she was dependent for all mobility, including transferring, and her care plan identified fall-related interventions including a bolster mattress, bed alarm, floor mat, and bed alarm education to staff for proper placement of pads under the shoulders. During observation of morning care, surveyors found the resident’s bed alarm device was not in place at the head of the bed and was not alerting staff to position changes while the resident was being rolled for peri-area care. CNA staff stated the alarm had been there the day before but could not determine how long it had been off or who removed it. A nursing care coordinator later found the white alarm box at the nurse’s station and replaced the battery; once reconnected, the alarm indicator light showed it was working. Record review also showed multiple prior falls from the bed or beside the bed, including incidents where the resident rolled out of bed, attempted to walk to the closet, and fell when the bed alarm did not sound because it was lower in the bed.
Failure to Monitor Dialysis Residents Before and After Treatments
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for two residents who required hemodialysis, including assessment of condition and dialysis access before and after treatments received at a certified dialysis facility. R9 had diagnoses including end stage renal disease, dependence on renal dialysis, paraplegia, severe protein-calorie malnutrition, a stage 3 sacral pressure ulcer, MRSA, and other serious conditions, and was documented as moderately cognitively impaired and dependent on staff for multiple activities of daily living. R17 had diagnoses including end stage renal disease, dependence on renal dialysis, traumatic brain injuries with hemorrhages, diabetes, CHF, and CKD, and was documented as severely cognitively impaired and needing staff assistance for dressing and transfers. R9’s care plan included hemodialysis three times weekly, no blood pressure or blood draws in the graft arm, monitoring for bleeding after dialysis, and monitoring/documenting/reporting edema and signs of infection at the access site. R17’s care plan also included hemodialysis and no blood pressure or blood draws in the graft arm, along with an emergency kit and hemostatic supplies for a bleeding fistula. Physician orders for both residents directed vital signs before and after dialysis on their scheduled dialysis days. Review of the records found the medication and treatment administration records did not document vital signs for either resident, and comprehensive assessments of the dialysis port/access site before or after return from dialysis were not documented. For R9, the electronic record showed only one blood pressure reading on dialysis days and multiple missing entries on the vital sign/weight flowsheets sent to dialysis. For R17, the electronic record also showed only one blood pressure reading on dialysis days, with some days lacking blood pressure documentation and the vital sign flowsheet unavailable for review. The DON stated the facility did not have a policy and procedure for dialysis assessments, and the NCC stated that vitals, weight, and site checks should be completed before dialysis and again when the resident returns.
Failure to Ensure Staff Training on Abuse, Neglect, Exploitation, and Dementia Care
Penalty
Summary
The facility failed to ensure that all staff received required training on abuse, neglect, exploitation, and dementia care, as outlined in its own policy. The policy states that staff and volunteers must receive education on resident mistreatment, neglect, abuse, exploitation, and misappropriation of property upon hire and annually thereafter. However, review of staff education records revealed that one CNA did not have documented abuse education training, and another CNA's annual training was missed due to their casual employment status. Additionally, the RN's training was not up to date. Interviews with staff and the Director of Nursing (DON) confirmed that there were lapses in the completion and monitoring of required training. The DON acknowledged that new hire training was not completed for at least one CNA before they began working with residents and that there may be other staff with lapses in annual training due to the transition to a new tracking system. These deficiencies have the potential to affect all 134 residents in the facility.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent and respond to abuse, neglect, and misappropriation of resident property. In one incident, a certified nursing assistant (CNA) was instructed to physically restrain a resident while another CNA administered medication, which involved holding the resident's arms and face and forcibly giving medication. This incident was not immediately reported to the Director of Nursing (DON) or the Nursing Home Administrator, and the accused staff continued to work in the facility for several days after the incident before it was reported. The facility did not submit a required facility-reported incident to the state agency for two separate abuse allegations, nor did it report the abuse to law enforcement or notify the resident's representative. Additionally, a full investigation into the allegations of abuse for two residents was not completed, and there was a lack of documentation regarding notification of the resident's representative. The report also details that staff education on abuse, neglect, mistreatment, and misappropriation of resident property was not consistently completed upon hire or annually. One CNA did not have recorded abuse education training, and the system for ensuring all staff received required training was inadequate, relying only on nurse clinical coordinators to monitor completion. Signed memorandums for re-education after the incident did not include all staff signatures and did not cover the full scope of the abuse policy, such as ensuring resident safety, reporting to state agencies, and law enforcement notification. The DON acknowledged that some staff had lapses in annual training and that a new system for tracking training was still being developed. In another incident, law enforcement was contacted by a resident's family member regarding an allegation of abuse. Although law enforcement visited the facility, the facility did not submit a facility-reported incident to the state agency. The DON stated that the allegation was not reported or investigated because it was believed to be unfounded due to previous similar reports. The facility's failure to report, investigate, and document these incidents, as well as to ensure staff were properly trained, represents a breakdown in the implementation of its abuse prevention policies and procedures.
Failure to Notify Guardian of Abuse Allegation and Investigation Findings
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment about an allegation of abuse and the subsequent investigation findings. The resident, who had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, was under a court-appointed permanent guardianship due to incompetency and was subject to an involuntary order to treat with psychotropic medications. The resident's care plan specifically required that the physician and guardian be notified of any change in condition, including medication non-compliance. Despite this, when an allegation of staff abuse involving the resident was reported and substantiated, there was no documentation that the guardian was informed of either the incident or the investigation results. During the survey, the guardian confirmed in an interview that she had not been notified of the incident or the findings, and this was the first time she was hearing about the event. The facility's policy required that the resident or their representative be informed of any incident and the results of investigations. The DON stated she believed the guardian had been notified but could not provide documentation to support this. The lack of notification to the guardian was confirmed through record review and interviews.
Inappropriate Use of Physical Restraints During Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. The facility's policy requires that physical restraints only be used after a comprehensive assessment, as a last resort, and with a physician order and consent from the resident's legal representative. However, staff used physical force to administer oral psychotropic medications to a resident with severe cognitive impairment and a history of psychiatric disorders, including anxiety, depression, and psychosis. The resident had a court order for involuntary medication, and the care plan specified disguising medications in food or drink, but did not include the use of physical restraints for medication administration. On two occasions, staff members held the resident's arms and face to forcibly administer medications by mouth, despite the resident not being physically aggressive but attempting to push the medications away. One CNA held the resident's hands above his head and then at his sides, while another held the resident's face to open his mouth, and a nurse supervised the process. Staff justified their actions by citing the court order for medication, but there was no physician order for the use of physical restraints, nor was this intervention included in the care plan. The medication administration record did not document reasons for refusals or alternative interventions attempted. The incident was reported by a CNA who expressed concern about the use of force, and an internal investigation substantiated the allegation of inappropriate use of physical restraints. The facility's documentation and staff interviews confirmed that the use of physical force occurred during medication administration, in violation of facility policy and regulatory requirements. The resident's care plan and physician orders did not authorize the use of physical restraints for this purpose.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of alleged physical abuse in accordance with federal and state requirements. In two separate cases, allegations of abuse involving two residents were not reported to the State Agency or local law enforcement as required. In the first case, local law enforcement notified the facility of an abuse allegation concerning a resident with cognitive impairment and psychiatric diagnoses, but the facility did not submit a Facility Reported Incident (FRI) to the State Agency. The Director of Nursing (DON) stated that due to previous unfounded reports from the resident and his sister, the facility did not believe the allegation warranted reporting or investigation. In the second case, a resident with psychiatric and cognitive diagnoses was subjected to physical restraint and threats by staff during medication administration, as witnessed by a CNA. The CNA reported the incidents to a nurse manager, who acknowledged the behavior as abuse but did not immediately escalate the report to the DON. When the DON was eventually notified, an internal investigation was conducted, and the staff member involved was terminated. However, the facility did not report the allegation to the State Agency or local law enforcement, and the DON stated the decision was made not to report because the notification was delayed and they anticipated being cited for late reporting.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with a history of mild cognitive impairment, personality disorder, delusional disorders, unspecified psychosis, and depression. On the date in question, the resident's sister contacted local law enforcement to report concerns that the resident was being abused and did not feel safe. Law enforcement arrived at the facility to address the allegation. Facility documentation showed that staff were aware of the report and notified relevant parties, including the resident's guardian, Adult Protective Services social worker, and supervisory staff. However, there was no documentation of any investigation into the abuse allegation as required by facility policy. During an interview, the Director of Nursing stated that both the resident and the resident's sister had made multiple prior unfounded allegations of abuse and, as a result, did not believe this particular allegation warranted reporting or investigation. The facility's policy requires that all reports of abuse, neglect, or mistreatment be promptly and thoroughly investigated, but this was not followed in this instance. No root cause investigation or analysis was documented for the reported allegation.
Unlicensed Staff Administered Prescription Medications
Penalty
Summary
Prescription medications for one resident were administered by a Certified Nursing Assistant (CNA), contrary to facility policy and regulatory requirements. The resident had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, and had physician orders for Haloperidol Lactate and Valium. Facility documentation and interviews revealed that the CNA administered these medications using food, ice cream, and a syringe, with another staff member holding the resident's hand and the CNA holding the resident's chin to squirt the medication into the resident's mouth. This administration was performed under the direct supervision of a Registered Nurse (RN), but the CNA had not completed any medication administration training or competency evaluation. Facility policies explicitly state that only licensed nurses or nurse technicians are permitted to administer medications, and that CNAs may not administer medications except for applying topical creams to unbroken skin or providing oral care with mouthwashes. Despite this, the Director of Nursing (DON) confirmed that it was common practice for CNAs to administer medications under direct nurse supervision, without additional training or competency assessment. This practice was in direct violation of both facility policy and regulatory standards, resulting in the identified deficiency.
Failure to Provide Timely Updates on Resident Council Concerns
Penalty
Summary
The facility failed to provide timely updates to residents regarding concerns raised during resident council meetings, as required by their own policy. Specifically, three cognitively intact residents with various medical conditions, including multiple sclerosis, quadriplegia, and coronary artery disease, reported that issues such as staff discussing other residents, insufficient staffing, and long call light response times were repeatedly brought up in meetings. Despite these concerns being documented in the Resident Voice Minutes over several months, residents stated they did not receive follow-up or updates from administration or staff about actions taken to address these issues. Interviews with residents and staff revealed that the Director of Nursing did not regularly attend resident council meetings and was unaware of when they occurred. The Activity Director did not document follow-up conversations with residents, and the Case Manager confirmed there was no formal process for following up on concerns voiced in resident council. Residents expressed frustration that their concerns, particularly about staffing and call light response times, were not addressed or communicated back to them, impacting their daily routines such as timely access to breakfast and coffee.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse between residents, as evidenced by two separate incidents involving three residents. In the first incident, a resident with severe cognitive impairment and dementia (BIMS score 3/15) was involved in a verbal altercation with another resident who was cognitively intact (BIMS score 15/15) and had a history of behavioral symptoms. The cognitively intact resident was observed yelling threatening statements, while the cognitively impaired resident pushed a medication cart toward him, resulting in the latter losing balance and sustaining a bruise and abrasion after falling. In the second incident, a resident with moderate cognitive impairment and dementia (BIMS score 9/15) was found hitting the same severely cognitively impaired resident in the face. The aggressor believed the other resident was in his bed, and this event was discovered when a CNA responded to the victim's calls for help. The incident was reported to law enforcement, and the aggressor had a recent medication change that may have contributed to impulsive behavior. Both incidents were confirmed by the DON as instances of physical and verbal abuse between residents.
Failure to Conduct Thorough Investigation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation following an alleged abuse incident involving two residents. According to the facility's policy, when an incident or suspected incident of abuse is reported, the investigation should include resident statements. In this case, a resident-to-resident altercation occurred when one resident struck another in the head with a remote after a verbal exchange. Both residents involved were cognitively intact, as indicated by their Brief Interview Mental Score (BIMS) of 15 out of 15. Law enforcement was called, and the residents were separated immediately following the incident. Despite the policy requirements, the investigation did not include interviews with other residents or further investigative steps beyond the immediate response. Staff interviews revealed that no one was instructed to interview other residents or provide additional education to staff. The DON confirmed that no further investigation was conducted, believing the event to be isolated. This lack of a comprehensive investigation did not align with the facility's policy and left the incident insufficiently examined.
Failure to Implement Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan interventions after the resident expressed suicidal ideation. The resident, who had a history of chronic suicidal ideation, mild cognitive impairment, legal blindness, abnormal gait, osteoarthritis, and anxiety disorder, repeatedly stated she wanted to kill herself. Despite these statements, Certified Nursing Assistants (CNAs) did not notify the nurse on duty or the Nurse Care Coordinator as required by the care plan. The care plan specifically directed staff not to leave the resident alone, to immediately notify nursing staff, and to provide one-to-one supervision until a nurse could assess the resident's safety and implement further interventions. On the day of the incident, the resident was found alone in her room, repeatedly calling for help and expressing a desire to die. Staff present on the unit acknowledged that the resident often made such statements and described their response as attempting to calm her and documenting the behavior, but did not escalate the situation to nursing staff for assessment. The CNAs reported that when the resident was disruptive, she was placed in her room alone to avoid agitating other residents, contrary to the care plan's instructions. There was no documentation in the progress notes of the resident's suicidal statements on the day in question, and neither the nurse on duty nor the Nurse Care Coordinator were informed of the incident. Both confirmed in interviews that they had not been notified and that the care plan should have been followed, including immediate assessment and supervision. The Director of Nursing also confirmed that the care plan's directives were not implemented as required.
Failure to Provide Non-Alarm Interventions and Proper Alarm Reduction for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that two residents at risk for falls were consistently provided with non-alarm interventions before and after the implementation of multiple alarms. Both residents were subjected to the use of several alarms simultaneously—one with five alarms and the other with four—without a documented plan to reduce alarm use or assess the necessity of concurrent alarms. The facility's own policies required that alarms be used on a short-term basis and that the interdisciplinary team review the potential for eliminating alarms while developing other strategies, but there was no evidence that these steps were followed. Additionally, alarm assessments were incomplete, with missing documentation and blank sections regarding alternative strategies and justification for alarm use. For one resident with mild cognitive impairment, legal blindness, abnormal gait, and anxiety disorder, alarms were used extensively, including a motion sensor, chair alarm, bed alarm, and a Tabs alarm. Observations revealed that the alarms were loud and disruptive, and the resident was unaware of the source of the noise. Despite the use of multiple alarms, the resident experienced several falls, some of which occurred when alarms failed to prevent self-transfers or were not in place. The care plan required the use of a gait belt for all transfers, but this was not consistently followed, and there was no documentation that nursing staff were notified when the resident refused the gait belt, as required by the care plan. For the second resident, who had dementia and a history of wandering and falls, multiple alarms were also used, including a bed alarm, chair alarm, motion sensor, and wander/elopement alarm. The care plan and assessments did not document the use of alternative interventions or a reduction plan for alarm use. There was also a lack of documentation in progress notes and social services notes regarding the discussion or justification of alarm use. Staff interviews confirmed that alarms were implemented based on the resident's history of falls, but there was no admission assessment or documentation of other options considered prior to alarm use.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure a resident's right to privacy was maintained when receiving mail. A resident, identified as R2, who is cognitively intact and able to communicate effectively, reported that facility staff opened their mail without permission. This practice began approximately five months prior to the survey, coinciding with R2's ordering of adult movies. R2, a registered sex offender with a history of child pornography, had previously signed a waiver in 1998 allowing mail to be opened during probation, which ended in 2002. Despite the end of probation, the facility continued to open R2's mail without a current waiver or consent. Interviews with facility staff, including a Certified Nursing Assistant, Nursing Care Coordinator, and Social Services staff, confirmed the practice of opening R2's mail. The Nursing Care Coordinator stated that mail is typically delivered unopened, but R2's mail is treated differently due to their criminal history. The Director of Social Services and a Social Worker acknowledged the challenges since R2's admission and confirmed that the waiver signed during probation was no longer valid. The facility's policy on mail distribution emphasizes residents' rights to privacy and assistance with mail upon request, which was not adhered to in R2's case.
Lack of Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received a performance review every 12 months, affecting three out of five CNAs reviewed. Specifically, CNAs H, I, and J, who have been employed since 06/14/22, 07/13/17, and 08/15/22 respectively, did not have documented annual performance reviews. Upon inquiry, the Human Resources Manager confirmed that the facility did not have a system in place to conduct these reviews, and no performance reviews had been completed for any staff. This deficiency had the potential to impact all 147 residents residing in the facility.
Failure to Report Resident Altercation and Submit Investigation
Penalty
Summary
The facility failed to report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the required 5-day investigation report within the stipulated timeframe. This deficiency was identified during a surveyor's review of an altercation involving a resident with dementia and behavioral issues. The resident, who has a history of short-term and long-term memory problems, as well as physical and verbal behavioral symptoms, was involved in an incident where they attempted to take candy from another resident, resulting in a willful slap. This action was deemed potentially harmful and should have been reported as per the facility's policy and state regulations. The resident's care plan, which was initiated to manage psychopharmacological medication and behavior, included interventions to prevent altercations with peers. Despite these measures, the incident occurred, and the Director of Nursing acknowledged that the altercation should have been reported as it was considered willful. The failure to report the incident and submit the investigation in a timely manner highlights a lapse in adhering to the facility's abuse, neglect, mistreatment, and misappropriation of resident property policy and procedure.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide proper notification of transfer to two residents, R56 and R127, who were hospitalized. R56, who was cognitively intact and capable of making decisions, was transferred to the hospital after experiencing a fever and requesting the transfer. However, R56 was not given a written notice of the transfer, which is a requirement. During an interview, the Director of Nursing (DON) admitted that the facility does not provide written notifications to residents or their representatives when transferring them to the emergency room. Similarly, R127, who had diagnoses including paranoid schizophrenia, type 2 diabetes, dementia, and anxiety, was transferred to the hospital without receiving a written notice of the transfer. The surveyor was unable to find any documentation of a discharge/transfer notice for R127's hospitalization. When asked, the DON confirmed that the facility did not issue a transfer notice for R127's hospital transfer. This lack of proper notification is a deficiency in the facility's compliance with regulations regarding resident transfers.
Failure to Implement Care Plan for Resident with Huntington's Disease
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for a resident diagnosed with Huntington's disease and pneumonitis due to inhalation of food and vomit. The care plan specified that the resident required the head of the bed (HOB) to be elevated 45 degrees during and thirty minutes after tube feeding to accommodate their condition. However, during an observation by a surveyor, it was noted that the resident was positioned flat with their head resting at pillow height, contrary to the care plan's requirements. This position was not adjusted during the tube feeding administration by Registered Nurse (RN) C. Upon inquiry by the surveyor, RN C acknowledged that the bed was not at the required angle and subsequently adjusted it. Further discussions with the supervisor, RN D, and the Director of Nursing (DON) B confirmed that the expectation was for the nurse to ensure the bed was elevated to 45 degrees before starting the procedure, especially given the resident's condition that affects gastric motility and predisposes them to emesis. The failure to adhere to the care plan's directives constituted a deficiency in the care provided to the resident.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R34 and R100. R34, who has dementia and a seizure disorder, was identified as high risk for falls. Despite having a care plan that included the use of a chair sensor alarm, the facility's fall-root cause analysis revealed that the alarm was either inappropriately placed or not under the resident during two separate falls. This indicates a failure to follow the care plan and ensure the safety interventions were in place. R100, diagnosed with dementia with agitation and other behavioral issues, was supposed to have 1:1 supervision to maintain safety. However, during an incident, a new CNA, unfamiliar with R100, was unable to prevent the resident from engaging in a physical altercation with another resident. The CNA was covering for a more experienced CNA on break, and the lack of proper training and supervision led to the incident. The Director of Nursing acknowledged the expectation for the CNA to intervene before the altercation occurred, highlighting a lapse in staff training and supervision protocols.
Uncovered Food Transported to Residents' Rooms
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not covering food items during transportation to residents' rooms. The facility's policy, titled 'Dining - Meal Service,' mandates that all food must be covered when transported through the unit. However, during an observation, Certified Nursing Assistants (CNAs) were seen carrying trays with uncovered cake and drinks to residents' rooms. This occurred with three residents, who were eating in their rooms, and the uncovered items were transported down the hallway, potentially leading to contamination. The Director of Hospitality, responsible for kitchen and dining services, confirmed that all food and drinks should be covered when leaving the dining area, indicating a lapse in following the established policy.
Failure to Administer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that vaccinations were reviewed, offered, or administered for one of the sampled residents, identified as R23. The resident was admitted with severe cognitive impairment and diagnoses of chronic cough and obstructive sleep apnea. During the survey, the Infection Preventionist was unable to provide immunization information for R23, directing the surveyor to another nurse. When the surveyor followed up with Registered Nurse F, it was revealed that there was no proof that R23 had been offered or received a pneumococcal vaccine. The process for screening and administering immunizations upon admission was questioned, and RN F admitted that there was no clear process in place for residents who transferred between units. This lack of a systematic approach led to the oversight in ensuring R23 received the necessary pneumococcal vaccination, as there was no documentation or evidence of the vaccine being offered or administered. The deficiency highlights a gap in the facility's immunization protocol, particularly for residents transferring between units.
Failure to Update Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to provide care and treatment based on professional standards of practice for a resident at risk for pressure injuries. The resident, identified as R4, developed a new stage 2 pressure injury on the coccyx, which was noted on June 1, 2024, and healed by July 9, 2024. Despite the development of this pressure injury, the facility did not update R4's care plan or repositioning schedule to align with current standards of practice, which contributed to the deficiency. R4's care plan, initiated in December 2022, identified the potential for pressure ulcer development due to immobility and incontinence. However, no changes were made to the interventions following the development of the pressure injury. The care plan included interventions such as educating caregivers on skin breakdown causes, following facility protocols, and monitoring skin status. Despite these interventions, the care plan was not revised to address the new pressure injury or to adjust R4's repositioning schedule. Observations by the surveyor revealed that R4 was seated in a wheelchair for extended periods, sometimes exceeding four hours, without repositioning. The CNA responsible for R4's care was unaware of any changes to the repositioning schedule following the pressure injury's development. The Nurse Care Coordinator acknowledged that R4's care plan should have been updated to include more frequent repositioning, ideally every two hours, to prevent further pressure injuries. This oversight in care planning and execution led to the deficiency noted in the report.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime, specifically an allegation of sexual abuse. The incident involved a resident with diagnoses including congestive heart failure, anxiety disorder, major depressive disorder, type 2 diabetes, and heart failure. On 03/08/24, a family member reported to a registered nurse that the resident had alleged an Amish man was having his way with them. However, this allegation was not reported immediately as required by law. The Director of Nursing acknowledged that the report should have been made sooner, but it was not submitted to the State Agency until 03/14/24, and the police were also not notified until that date. This delay in reporting violated the requirement to report such allegations within 2 hours. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property states that reports of abuse are to be promptly and thoroughly investigated, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Owen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Health Services | 10.8 mi | ★★★★★ | 2 | 2 |
| Abbotsford Health Care Center | 11.1 mi | ★★★★★ | 7 | 0 |
| Oakbrook Health And Rehabilitation | 12.7 mi | ★★★★★ | 9 | 0 |
| Aspirus Care & Rehab-medford | 16.1 mi | ★★★★★ | 2 | 0 |
| Three Oaks Health Services | 25.6 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.